Abstract Body: Introduction: Stroke prevalence is highest in adults ages >65 years, the majority of whom are Medicare beneficiaries. Fee-for-Service (FFS) Medicare incentivizes utilization by paying for each service. Medicare Advantage (MA) uses capitated payments to reduce overutilization. It is unknown if MA beneficiaries with stroke receive more stroke prevention care as a strategy to lower utilization. We examine this question by reviewing studies comparing clinical measures, utilization, and outcomes in FFS and MA.

Methods: We performed an empirical integrative narrative review of the Pubmed, Embase, and OVID databases according to PRISMA guidelines to compare stroke care between MA and FFS. Cholesterol control, blood sugar management, tobacco cessation, and blood pressure management were chosen using the American Heart Association’s Life’s Crucial 9 for their Medicare coding availability. Anticoagulation for atrial fibrillation (AF), acute and post-acute care utilization, and outcomes were added. We included studies if >20% of the patient population had strokes and excluded studies prior to the Medicare Modernization Act (2003) to accurately assess MA.

Results: 9/544 studies met inclusion criteria (Figure 2). One found higher LDL levels (81.5 mg/dL vs 78.9 mg/dL) and statin prescription rates (Standardized Difference 32%) in MA than FFS (2). MA beneficiaries had slightly higher HgbA1C in one study. Two showed mixed rates of antihyperglycemic medications in MA. Tobacco cessation counseling was more likely in MA (aOR 1.05, 95% CI 1.02-1.09) (2). MA beneficiaries had slightly higher systolic blood pressure but no difference in blood pressure control. Oral anticoagulation use for AF was higher in MA than FFS (75.52% vs 69.96%), as was adherence (41.14% vs 33.70%) (7). Index hospitalization and post-acute care utilization, including hospital readmission, appeared lower in MA. We calculated higher Functional Independence Measure gains in MA (Figure 3). One study showed non-significant lower mortality in MA (4). Another showed lower mean mortality and 0.5% higher 90-day mortality in MA (9).

Conclusion: Published studies suggested that MA emphasizes preventative care for stroke patients, particularly for hyperlipidemia, smoking, and AF, without showing favorable selection in MA. Acute and post-acute care utilization was lower in MA. Improvements in functional outcomes were greater. Mortality data was mixed. Future cohort studies are needed to better understand these dynamics.